Patient selection in outpatient parenteral antimicrobial therapy

Home nursing and self-administered outpatient parenteral antimicrobial treatment: a comparison of demographics and outcomes from a large regional hospital in Queensland, Australia

BACKGROUND

Outpatient parenteral antimicrobial treatment (OPAT) is a safe and effective therapy used in several settings across Australia. As OPAT services expand their inclusion criteria to include complex patient populations, there is an increased need for selecting appropriate patients to receive either healthcare-administered OPAT (H-OPAT) or self-administered OPAT (S-OPAT).

AIMS

To describe patient demographics, diagnosis, microbiology and outcomes of patients treated by H-OPAT and S-OPAT within the Sunshine Coast Hospital and Health Service, Australia.

METHODS

Data on demographics, diagnoses, treatment and outcomes on all patients treated by H-OPAT and S-OPAT from March 2017 to December 2019 were collected retrospectively.

RESULTS

One hundred and sixty-five patients (62.26%) were enrolled in H-OPAT and 100 patients (37.74%) in S-OPAT. S-OPAT patients were significantly younger. H-OPAT patients were more comorbid. Bone and joint infections were the most treated infections and were more likely to be treated by S-OPAT. There was no difference in treatment duration, cure and complication rates between S-OPAT and H-OPAT. Longer duration of therapy was associated with more complications. Treatment failure was associated with infections due to multiple organisms, number of comorbidities and treatment of surgical site, skin and soft tissue infections.

CONCLUSIONS

There were significant differences in demographics between H-OPAT and S-OPAT without any difference in outcomes. Overall failure and complication rates were low. Higher rates of treatment failure were predicted by the diagnosis, number of comorbidities and number of organisms treated.

Successful Integration of Clinical Pharmacists in an OPAT Program: A Real-Life Multidisciplinary Circuit

Outpatient parenteral antimicrobial therapy (OPAT) programs encompass a range of healthcare processes aiming to treat infections at home, with the preferential use of the intravenous route. Although several barriers arise during the implementation of OPAT circuits, recent cumulative data have supported the effectiveness of these programs, demonstrating their application in a safe and cost-effective manner. Given that OPAT is evolving towards treating patients with higher complexity, a multidisciplinary team including physicians, pharmacists, and nursing staff should lead the program. The professionals involved require previous experience in infectious diseases treatment as well as in outpatient healthcare and self-administration. As we describe here, clinical pharmacists exert a key role in OPAT multidisciplinary teams. Their intervention is essential to optimize antimicrobial prescriptions through their participation in stewardship programs as well as to closely follow patients from a pharmacotherapeutic perspective. Moreover, pharmacists provide specialized counseling on antimicrobial treatment technical compounding. In fact, OPAT elaboration in sterile environments and pharmacy department clean rooms increases OPAT stability and safety, enhancing the quality of the program. In summary, building multidisciplinary teams with the involvement of clinical pharmacists improves the management of home-treated infections, promoting a safe self-administration and increasing OPAT patients' quality of life.

Adverse Events and Healthcare Utilization Associated With Outpatient Parenteral Antimicrobial Therapy Among Older Versus Younger Adults

Among older (n = 204) versus younger (n = 253) adults, there was no difference in adverse events (adjusted odds ratio [aOR] = 0.98; 95% confidence interval [CI] = 0.6-1.6) or healthcare utilization (incidence rate ratio = 1.09; 95% CI = 0.9-1.3) within 30 days after discontinuing outpatient parenteral antimicrobial therapy. Vancomycin (aOR = 1.92) and oxacillin (aOR = 3.12) were independently associated with adverse events.

Sociodemographic and clinical factors associated with acceptance of outpatient parenteral antibiotic therapy in a Singapore tertiary hospital from 2014 to 2017

Outpatient parenteral antibiotic therapy (OPAT) can facilitate early discharge; however, not all offered OPAT can accept. We assessed factors associated with acceptance of OPAT in a large Asian tertiary hospital cohort. From 2014 to 2017, we reviewed all referrals to Singapore General Hospital's (SGH) Outpatient Parenteral Antibiotic Therapy (OPAT) service. We compared differences in sociodemographic and clinical factors between patients who opted for OPAT and those who declined, using chi-square test for univariate analysis and logistic regression for multivariate analysis. From 2014 to 2017, a total of 1406 OPAT referrals were made. Of these, 95.9% (1349/1406) were deemed suitable for OPAT. Amongst those suitable, 90.0% (1213/1349) accepted OPAT treatment. On multivariate analysis, being independently ambulant (aOR = 3.46, 95%CI = 2.21-5.37) was independently associated with higher odds of acceptance for OPAT; whereas, patients with peripheral vascular disease had lower odds of accepting OPAT (aOR = 0.32, 95%CI = 0.16-0.62). Lower socioeconomic status (SES) was closely associated with rejection of OPAT, with markers of both individual-level SES (subsidized ward class) and area-level SES (staying in a public rental flat) being independently associated with lower odds of OPAT preference. Distance and travel time were not associated with OPAT acceptance. The top reasons for rejecting OPAT were lack of caregiver (n = 35), mobility issues (n = 24), financial issues (n = 24), and difficulty caring for the line (n = 21). Comorbidities, mobility, and financial issues are important factors to consider when determining suitability for OPAT. More can be done to improve accessibility of OPAT amongst lower-income patients and those staying in lower-SES areas.

An Assessment of an Outpatient Antimicrobial Therapy Program in a Rural Medical Center : A Retrospective Chart Review

Current literature supports outpatient parenteral antimicrobial therapy (OPAT). This article presents results from a research study that evaluated an OPAT program that treated community-acquired pneumonia. If patients had the opportunity to receive outpatient intravenous antibiotics for community-acquired pneumonia, would this prevent future hospitalization? Was there a decrease in hospital admissions? An informal cost-benefit analysis comparing OPAT with inpatient hospital admissions for the same disease was also reviewed to provide evidence whether there was a change. What was the overall health care cost savings? The medical charts of 50 patients with confirmed pneumonia who had received OPAT in a 3-month period were reviewed. A retrospective medical record review was performed. All patients were evaluated by the in-house OPAT team. The resulting analysis provided evidence that an estimated savings of approximately $2100 per day would be achieved by decreasing hospital readmissions for patient who had been treated with OPAT. The conclusion of this study provides evidence that the implement of an OPAT program was, and is, essential for patient care and evidence-based best practice adherence.

Predictors of Unplanned Hospitalization in Patients Receiving Outpatient Parenteral Antimicrobial Therapy Across a Large Integrated Healthcare Network

Background

Outpatient parenteral antimicrobial therapy (OPAT) prescribing has increased along with the trend toward early discharge of hospitalized patients who have infections. There is limited literature that assesses unplanned hospitalizations during OPAT. This study aims to elucidate the predictors of unplanned hospitalization in OPAT patients after discharge from acute-care facilities within Carolinas HealthCare System (CHS). Understanding these predictors may inform future interventions to improve treatment efficacy and patient outcomes.

Methods

The study cohort included hospitalized patients aged >19 years who initiated OPAT in an acute-care facility within CHS in 2014–2015. Patients who had OPAT prescribed at an ambulatory-care facility were excluded. The primary outcome was unplanned hospitalization anytime during the at-risk time from discharge through 90 days.

Results

The unplanned hospitalization rate for the cohort was 18.5%. In adjusted analysis, having OPAT delivered at a skilled nursing facility was associated with a 46% (incident risk ratio = 1.46; 95% confidence interval = 1.04–2.06) increased risk of an unplanned hospitalization compared with patients receiving OPAT at home after adjustment for demographics, comorbidities, indication, treatment duration, and antimicrobial prescribed. Infusion, dialysis, and rehabilitation centers had the lowest rates of unplanned hospitalizations.

Conclusions

These results suggest that the location of OPAT delivery is associated with unplanned hospitalizations and that older patients need additional support during OPAT.

Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement

These good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) are an update to a previous consensus statement on OPAT in the UK published in 1998. They are based on previous national and international guidelines, but have been further developed through an extensive consultation process, and are underpinned by evidence from published literature on OPAT. They provide pragmatic guidance on the development and delivery of OPAT services, looking at all aspects of service design, care delivery, outcome monitoring and quality assurance, with the aim of ensuring that OPAT services provide high-quality, low-risk care, whatever the healthcare setting. They will provide a useful resource for teams developing new services, as well as a practical set of quality indicators for existing services.

Optimizing delivery of care for patients with MRSA infection: focus on transitions of care

Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; those infected with methicillin-resistant strains have longer hospital stays and higher total costs compared with those infected by methicillin-susceptible strains. A multidisciplinary team of health care providers, including hospitalists and other hospital-based physicians, clinical pharmacists, infectious disease specialists, infection control professionals, and case managers, is key to improving treatment and outcomes in these patients. Optimizing transitions of care for hospitalized patients with S aureus infections can improve quality and reduce total costs of care. Hospital length of stay can be shortened by initiating timely, appropriate empiric therapy and by transitioning suitable patients to outpatient antimicrobial therapy. The number of hospitalizations can be reduced by identifying patients who are suitable candidates for initial outpatient antimicrobial therapy. Consistent with good antimicrobial stewardship, the risk of resistance can be minimized by de-escalating empiric therapy to a more narrow-spectrum agent once culture and susceptibility testing results are known. There are several antimicrobial agents available for the management of S aureus infections, including methicillin-resistant S aureus. Consideration of these agents' characteristics may facilitate optimal transition of patients through health care settings.

Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patients to self-administer at home? A retrospective analysis of a large cohort over 13 years

OBJECTIVES

Provision of outpatient parenteral antimicrobial therapy (OPAT) is an evolving field, facilitating discharge from hospital for selected patients with serious infections. We report on a large OPAT cohort focusing on the practice of supervised parenteral antibiotic administration in the community by patients and relatives, which we collectively term 'self-administration'. To distinguish between healthcare professional OPAT and self-administered OPAT, we have coined the terms H-OPAT and S-OPAT, respectively.

PATIENTS AND METHODS

We analysed data on 2059 OPAT episodes collected prospectively over a 13 year time period from 1993 to 2005.

RESULTS

Clinical diagnosis, microbiology and antibiotics in this OPAT series are comparable to those previously reported. We identified no excess complications or hospital re-admissions in the S-OPAT group compared with the H-OPAT group.

CONCLUSIONS

Self-administration of intravenous antimicrobial therapy, in selected patients under the supervision of a specialist team, is a safe and feasible strategy.

Intravenous antibiotics for chronic rhinosinusitis: are they effective?

PURPOSE OF REVIEW

Antibiotics have been used commonly in chronic rhinosinusitis, often because chronic rhinosinusitis has features of a prolonged bacterial sinusitis, including abnormal CT findings and positive bacterial cultures. The advent of peripherally inserted central catheters has enabled outpatient parenteral antibiotic therapy to become a convenient means of delivering potent antibiotics for various conditions when oral antibiotics may not be effective or appropriate. Chronic rhinosinusitis has been included as a condition that may benefit from outpatient parenteral antibiotic therapy; however, there are few studies that document its success and, furthermore, chronic rhinosinusitis may not always be an infectious process.

RECENT FINDINGS

Three recent uncontrolled retrospective studies examined outpatient parenteral antibiotic therapy in chronic rhinosinusitis. In one series outpatient parenteral antibiotic therapy was used as an adjunct to sinus surgery, in another it was used as an alternative to sinus surgery in the pediatric population, and in the third it was used as temporary resolution for adult patients who had failed other therapies including sinus surgery. Short-term success rates were reported in the range of 29 to 89%, but relapse rates were as high as 89%. Complication rates in theses studies ranged from 14 to 26%, including medication reactions and intravenous line problems.

SUMMARY

The role of outpatient parenteral antibiotic therapy in the treatment of chronic rhinosinusitis has not been universally established. Although outpatient parenteral antibiotic therapy may have a role in avoiding sinus surgery in select pediatric populations, the contribution to a lasting resolution in adult patients is less clear and there are possible complications. Recognizing subsets of chronic rhinosinusitis patients for whom outpatient parenteral antibiotic therapy is appropriate will be the challenge for the future.

Outpatient intravenous antimicrobial therapy for the practicing orthopaedic surgeon

The medical treatment of many musculoskeletal infections requires prolonged intravenous antimicrobial therapy, much of which is administered outside the hospital under the guidance of an infectious disease specialist. The essential elements of patient selection, antimicrobial administration, and clinical and laboratory monitoring of outpatient intravenous antimicrobial therapy for adult patients with musculoskeletal infection is described in the current study. Orthopaedists who treat patients with musculoskeletal infection should know the essential details of outpatient intravenous antimicrobial therapy to optimize the medical and surgical treatment of patients with these infections.

Ambulatory use of parenteral antibacterials: contemporary perspectives

Outpatient parenteral antimicrobial therapy (OPAT) offers increased patient comfort and convenience in appropriately selected patients who require parenteral antibacterial therapy, as well as opportunity for cost savings. Home-based programmes, with drugs being administered by the patient or the caregiver, have become the norm in the USA. Choice of drugs for OPAT is based on antimicrobial spectrum, dosage regimen, drug stability, toxicity profile, and cost. Over the past decade, availability of sophisticated programmable pumps has allowed a wider range of antimicrobial agents to be used in the ambulatory setting. The most popular antibacterial agents in OPAT programmes in the USA are vancomycin and beta-lactams.

Practice guidelines for community-based parenteral anti-infective therapy

Practice guidelines for community-based parenteral anti-infective therapy (CoPAT) have recently been formulated in several countries. These guidelines emphasize the importance of teamwork and the interdisciplinary nature of CoPAT, and they use similar criteria for patient selection and evaluation, anti-infective agent selection and administration, and clinical monitoring. There are now guidelines or standards addressing the roles and responsibilities of the physician, nurse, and pharmacist in the delivery of CoPAT, and home care standards that address issues such as drug storage and preparation, treatment planning, and monitoring of ongoing care.